Va Form 10 0426 PDF Details

If you are a veteran who has recently been discharged from active duty, you may be wondering what benefits you are eligible for. One benefit that may be available to you is the VA Form 10 0426. This form can help you obtain disability compensation from the Department of Veterans Affairs (VA). In this blog post, we will discuss what the VA Form 10 0426 is, and how to complete it. We will also provide tips on how to submit your application for disability compensation.

You'll discover details about the type of form you would like to prepare in the table. It will tell you how much time it will take to finish va form 10 0426, exactly what parts you will need to fill in and a few further specific details.

Form NameVa Form 10 0426
Form Length2 pages
Fillable fields0
Avg. time to fill out30 sec
Other nameschampva meds by mail form, order va medical, veteran affairs form 10 0426, 0426

Form Preview Example

Department of Veterans Affairs Meds by Mail Order Form

A mail order prescription service for qualified CHAMPVA and Spina Bifida beneficiaries

This form is for Prescription Orders Only

Important Information

This form must be filled out completely including your Social Security number and Date of Birth for identification purposes. If you cannot be identified, your prescription will not be filled.

Attach the original prescription to this form. Photocopies of prescriptions are not accepted.

This order form is required EVERY TIME a written prescription from your medical provider is mailed.

This form is to be completed by the patient, family member, or caregiver with power of attorney.

Use a separate form for each patient or family member.

Medication delivery may take up to 21 days from the date you mail your order. To ensure that you have enough medication to last until your shipment arrives, request a second written prescription for a 30-day supply from your medical provider that can be filled at your local pharmacy.

This mail order service is provided only for maintenance medication―that is, medications that are required for extended periods of time. All immediate-use or one-time-use prescriptions and all CII controlled substance prescriptions must be obtained at your local pharmacy.

Patient Prescription Information

This form must be filled out completely - TYPE or PRINT information below:



Patient Name: (Last, First, Middle Initial)







Patient SSN



Date of Birth (mm-dd-yyyy)





































































Mailing Information (Type or Print where the prescriptions are to be mailed)


Patient Mailing Address:









Daytime Phone Number (Including Area Code):

Address 1




























































Address 2










Today's Date:



























































































Federal law requires that your medication be dispensed in a























container with a child resistant or safety cap. If you would like your










prescription with an “Easy-Open” lid, please sign below:























I request that these prescriptions and all refills of these


Is this a change of address?






prescriptions dispensed in “Easy-Open” or NON-child-resistant


Is this a permanent change?























Is this a temporary change?







































Medication Allergies

Health Conditions




No known allergies







Liver Disease

















Heart Problem











High Cholesterol

T Thyroid











Ulcer/Acid Reflux










Kidney Disease















Other (specify)





Other (specify)



Food Allergy (specify)











Page 1 of 2






































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DEC 2016









Where to Mail your Prescriptions:





If you live in one of the following states or

If you live in one of the following districts, states or

territories, mail your order form to the address

territories, mail your order form to the address

listed below:


listed below:


Alaska, American Samoa, Arizona, Arkansas,

Alabama, Connecticut, Delaware, Florida,

California, Colorado, Guam, Hawaii, Idaho, Illinois,

Georgia, Kentucky, Maine, Maryland,

Indiana, Iowa, Kansas, Louisiana, Michigan,

Massachusetts, Mississippi, New Hampshire,

Minnesota, Missouri, Montana, Nebraska, Nevada,

New Jersey, New York, North Carolina, Ohio,

New Mexico, North Dakota, Northern Mariana

Pennsylvania, Puerto Rico, Rhode Island, South

Islands, Oklahoma, Oregon, South Dakota, Texas,

Carolina, Tennessee, Vermont, Virginia, Virgin

Utah, Washington, Wisconsin, Wyoming.

Islands, Washington D.C., West Virginia.






Meds by Mail


Meds by Mail


PO Box 20330


PO Box 9000


Cheyenne, WY 82003-7008


Dublin, GA 31040-9000





How to Request Prescription REFILLS:

This form is for use when you send a paper prescription written by your medical provider. Refill orders should be placed by calling our automated refill system. Simply call 1-888-370-1699 and follow the voice prompts. Refill orders may also be placed using the refill slip that accompanies each shipment of medication. If you choose to reorder by mail, be sure to return your refill slip as soon as you receive your prescription order, as it may take up to 21 days to process your order. DO NOT DELAY in requesting your refills. Read the refill slip carefully, it contains information you will need concerning the number of refills remaining and the prescription expiration date.

E-prescribing Information

We now accept electronic prescriptions directly from your doctor. Ask your doctor if they can e-prescribe and tell them the name of the pharmacy is listed as: “Meds by Mail CHAMPVA”

Provider Information

Provider Name:

Provider Contact:



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DEC 2016

How to Edit Va Form 10 0426 Online for Free

This PDF editor was made to be as easy as it can be. As you comply with the following actions, the procedure for managing the meds by mail champva file is going to be effortless.

Step 1: Initially, click the orange button "Get Form Now".

Step 2: You can now manage your meds by mail champva. Our multifunctional toolbar permits you to include, erase, adapt, and highlight content or perhaps perform several other commands.

These particular sections will constitute the PDF template that you'll be filling out:

portion of empty spaces in va form 10 0426 printable

Make sure you enter your details within the segment Patient Name Last First Middle, Patient SSN, Date of Birth mmddyyyy, Patient Mailing Address, Daytime Phone Number Including, Mailing Information Type or Print, Address, Address, City, State, Zip, Is this a change of address Yes No, Medication Allergies, No known allergies, and Aspirin NSAIDS Cephalosporin.

Completing va form 10 0426 printable stage 2

Write the main particulars in Aspirin NSAIDS Cephalosporin, Tetracycline, Other specify, VA FORM JAN, VA FORM DEC, Arthritis Glaucoma Liver Disease, Other specify Food Allergy specify, Page of, and Page of field.

Finishing va form 10 0426 printable step 3

Take the time to specify the rights and responsibilities of the parties within the Provider Information, Provider Name, Provider Contact, VA FORM DEC, and Page of paragraph.

stage 4 to entering details in va form 10 0426 printable

Step 3: Choose the "Done" button. Next, you may export the PDF file - download it to your electronic device or send it through electronic mail.

Step 4: To avoid possible future troubles, you need to get a minimum of a few copies of every document.

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